News
First female RCGP Chair for half a century
Dr Gerada has a long involvement with the RCGP. She is currently Vice Chair of College Council and immediate past Chair of the Ethics Committee. She established the College’s groundbreaking Substance Misuse Unit and leads on the strategic and logistical delivery of the RCGP Annual National Conference, which this year takes place in Harrogate. Dr Gerada has been a GP in Lambeth since 1991 and is a partner at the Hurley Group of practices. Prior to general practice, she worked in psychiatry at the Maudsley Hospital in South London, specialising in substance misuse. No stranger to controversy, she has spoken out on the lack of career opportunities for younger doctors and constantly champions the need for GP leadership to prevent the privatisation of general practice. She is the Medical Director of the Practitioner Health Programme – a service for sick health professionals – and will continue to provide services to the PHP throughout her tenure as RCGP Chair. Dr Gerada said: “It is an enormous privilege
Take the Challenge EKC4 is going live
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Historic signing Egypt joins the RCGP
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Meet the new AiT Chair Greg Irving makes his debut
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Changing faces RCGP calls for new models of care for the elderly
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Clinical Update AF and new NICE guidance on unstable angina
to be appointed Chair of the RCGP at such a significant and historic time for general practice. As a frontline clinician, I am well aware of the major challenges – and opportunities – facing modern general practice and look forward to leading the College through the next stage of its development. “It is a daunting prospect but I hope I can build on Steve Field’s invaluable legacy and work with all our members, fellows and trainees to make the College even stronger and deliver ever higher standards of care for our patients.” The RCGP Chair is elected by College Council every three years. Unlike other medical Royal Colleges, the position of Chair – not President – is the top leadership role at the RCGP and the postholder is responsible for setting the strategic direction of the College and driving policy. Professor Field said: “Clare’s election is just reward for her major contribution to College life over many years. As well as being an extraordinary GP and leader, she provides me with unwavering support, counsel and tolerance in her role as Vice Chair, for which I am personally indebted to her. I know that she will continue to take the College forward with a lot of energy. “I want to also pay tribute to Dr Maureen Baker who was a worthy contender and who made the voting a very tough decision indeed. Maureen did a sterling job as Honorary Secretary for ten years and her work as the College’s Emergency Planning Lead during the swine flu pandemic was awe-inspiring.” Dr Gerada’s election means that for the first time in College history, the majority of the RCGP Officer posts will be occupied by women. Dr Iona Heath succeeded Professor David Haslam as President and Professor Amanda
election is just reward ❛ forClare’s her major contribution to College life over many years. An extraordinary GP and leader, she provides me with support, counsel and tolerance as Vice Chair. I know that she will continue to take the College forward with a lot of energy
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Fifty years on: Dr Annis Gillie was the only female Chair of the College before Dr Gerada
MAY 2010
Also in this issue...
Dr Clare Gerada (right) has been elected the new Chair of College Council – the first female Chair since Dr Annis Gillie 50 years ago. Dr Gerada will become the 21st RCGP Chair and will hold the post for three years, succeeding Professor Steve Field in November 2010. She will take on the title of Chair-elect in June 2010 to ensure an effective transition of leadership.
THE NEwsPAPEr OF THE rOyAl COllEGE OF GENErAl PrACTITIONErs
Professor Steve Field
Howe became Honorary Secretary – taking over from Dr Maureen Baker – in November 2009. For the first time, the two RCGP Vice-Chairs – who were previously appointed by the incoming Chair – will also be elected by Council, following recommendations in the RCGP Corporate Governance Review in 2007. Nominations for both positions close at noon on 12 May.
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A NICE Fellow RCGP headache champion takes national post
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Caring for carers RCGP launches award for practices
E A R LY B I R D B O O K I N G D E A D L I N E 2 8 J U N E 2 0 1 0
Sustainable
Primar Care growing healthy partnerships
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NEWS
why not take the Challenge and send us your feedback? chris elfes Essential Knowledge Challenge Lead Essential Knowledge Challenge (EKC) 4 is going live. This is the latest 50-item applied knowledge test linked to the RCGP Essential Knowledge Update 4 modules launched in November 2009. On the right is an example of the type of question you will find in the Challenge:
What is the estimated PREVALENCE of coeliac disease in the UK population? Select ONE option only. 1 in 10 A. B. 1 in 100 C. 1 in 500 D. 1 in 1,000 E. 1 in 5,000 Why should you take the EKC? ● All questions are based on the EKU e-learning modules and their linked reading material. ● To gain RCGP educational credits ● To test your current level of knowledge across a wide range of areas Answers to all questions will be released after the Challenge has been available for a period of 12 months ■ You can find the Challenge at http://elearning.rcgp.org.uk
New round of support on work and health The latest interactive workshops designed to help GPs with consultations around health and work issues have been announced by the RCGP. More than 1,000 GPs have now taken part in the half-day sessions which increase GPs’ skills and confidence for dealing with clinical issues around health and work. The content has been updated to include material on the new ‘Fit Note’ introduced last month. RCGP Chairman Professor Steve Field said: “We need to change the emphasis to create a culture that encourages patients to stay in work and that encourages employers to make adjustments allowing this to happen. “The workshops are a major step towards achieving this. They are extremely relevant and provide GPs with learning and strategies that they can directly apply to consultations back in practice.” ■ Book online at www.rcgp.org.uk/healthandwork
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Professor Field: The workshops are both relevant and important
june Holiday Inn LincoLn Best Western Huntingtower Hotel Perth Highpoint Centre Leicester Walnut Tree Hotel tAunton Latton Bush Centre hArLow Windermere Hydro Hotel Bowness on winderMere
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Engineers House Conference Centre BristoL Blackwell Grange Hotel dArLington Jury’s Inn Hotel BirMinghAM Village Swansea Hotel swAnseA Baden Powell House south Kensington, London Conference Centre at Lace LiverPooL
■ Further information via arosen@rcgp.org.uk
MRCGP INTERNATIONAL Examination Development Assessor (EDA) MALTA
Egypt signs up to the rCGP
The MRCGP [International] Board is seeking one Examination Development Assessor (EDA) to support the Malta College of Family Doctors (MCFD) to develop the MMCFD examination that will become a conjoint examination of the MCFD and the Malta MRCGP[INT]. This will become the licensing examination for Family Doctors in Malta. role To undertake work on behalf of the RCGP providing independent Quality Assessment on all aspects of the exam which forms Malta MRCGP[INT]. ■ To be familiar with the framework of the MRCGP International, the contents of the MRCGP[INT] workbook and the methodologies of assessment recognised by the RCGP. ■ The EDA will visit Malta on 8-14 July 2010 to assess all aspects of the examination, taking into account the Academic Framework and Quality Assurance Standards as detailed in the workbook. ■ The EDA will normally be accompanied by the Malta MRCGP International Development Advisor (IDA), whose role is to facilitate the visit, but not to contribute to the final report. ■ To provide a Recommendation Report to the MRCGP[INT] Board. ■ To revisit in the case of a negative recommendation by arrangement. Person specification ■ A current MRCGP or MRCGP[INT] examiner, or within two years of retirement, or equivalent examiner in a UK academic department of General Practice (essential) ■ Previous experience of working in the region (desirable) ■ An examiner with experience of Quality Assurance Assessment at a Higher Professional Education level (desirable) in return we can offer ■ A chance to participate in the latest developments in international assessment of General Practice/Family Medicine, the worldwide opportunity to attain the MRCGP International ■ An opportunity to work alongside enthusiastic colleagues, abroad and at home, committed to developing standards of General Practice/Family Medicine internationally, equivalent to the MRCGP in the UK, through the network of the MRCGP International ■ Full benefits and support including briefings, field support, full insurance, costs and the standard RCGP examiner professional fee to cover the agreed days worked and travelling If you are interested in applying for the role, please submit an up-to-date CV with a brief description outlining how you meet the requirements of the role (250 word max) on the last page, all as one document. All applications must be submitted by 5pm on Friday 14 May 2010. Interviews will be held on Friday 28 May 2010. Please email all applications to Andrey Gladkov, International Examination Officer, at agladkov@rcgp.org.uka 2
New signing: RCGP Chief Executive Hilary De Lyon and Professor Dr Samieh Amer, Medical Counsellor of the Egyptian Embassy, formalise the historic agreement, watched by Andrey Gladkov, International Examination Officer
The RCGP has signed an agreement granting MRCGP[INT] accreditation to the Egyptian Family Medicine Fellowship degree, a licensing postgraduate examination for family doctors in Egypt. The agreement formalises the collaboration between the College and the Egyptian Ministry of Health, meaning that successful graduates of the examination can now apply for International Membership of the RCGP. The RCGP partnership with the Higher Committee of Medical Specialties of the Egyptian Ministry of Health and the Egyptian Board of Family Medicine was fully supported by the Minister of Health of Egypt whose vision it was to establish the project. The Egyptian team set a very ambitious goal to achieve MRCGP[INT] accreditation within 14 months rather than the usual three years and additional resources were allocated by the Egyptian Ministry of Health in order to enlist more intensive support from the RCGP. Owing to the sheer scale of the project, five RCGP International Development Advisors (IDAs) were appointed to work closely with the Egyptian team of examiners from the Family Medicine Board. They were former RCGP President Professor Dame Lesley Southgate, Professor Peter McCrorie from St George’s
University, Dr Alistair Howitt FRCGP, Dr Navnit Chana FRCGP and Dr Graham Rawlinson FRCGP. Professor Valerie Wass FRCGP and Dr Anwar Khan FRCGP continue in the roles of External Examiners to the Egyptian Board of Family Medicine. Professor Wass was also heavily involved as Examination Development Assessor, together with Dr Mohammed Al Shafaee (Head of Family Medicine and Public Health Department, College of Medicine and Health Sciences, Sultan Qaboos University, Oman). MRCGP[INT] Medical Director Dr John Howard FRCGP said: “This achievement was catalysed by the excellent academic work achieved by our Egyptian colleagues, supported and guided by the RCGP team of International Development Advisors and the RCGP External Examiner to the Egyptian Board. The College can be really proud.” MRCGP[INT] accreditation was developed by the RCGP in response to the wishes of overseas colleagues and the worldwide need for development of high quality postgraduate assessments. It enables a country or region to develop an examination at the same level and academic rigour as the MRCGP in the UK, appropriately tailored to local needs, culture, health practices and education systems. ■ Further details of MRCGP[INT] Development Days – 28-30 June 2010 – are available from www.rcgp.org.uk/international_home/mrcgp _int/mrcgpint_development_days.aspx RCGP NEWS • MAY 2010
PROFILE
Clare gets ready for a new cycle in the College’s history Thrilled and terrified in equal measure – says Clare Gerada about the challenges facing her as the 21st RCGP Chair. Despite her trepidation, the College can rest assured that it will continue to be in excellent hands once current Chair Professor Steve Field steps down in November 2010. R GERADA’s election is the latest feather in the cap of a high-profile and illustrious career in general practice that will stand her in good stead for the challenges and opportunities that will come the way of general practice over the next three years. A freshly elected Government just getting into its stride, Revalidation and the College move, first to temporary accommodation at Tower Hill and then to the permanent building at Euston, are just three of the events that will happen on her watch – without even taking into account the unexpected. “It’s very difficult at the start of a job to say what your priorities are because events will happen that will take over. My priority will be, and has always been, the protection of generalism and preserving the future of general practice.” Dr Gerada has been a GP since 1992, when she became a partner for the Hurley Clinic in South London. The practice started life in 1969 – and remains on its current site – on the ground floor of a deprived 19-storey housing estate in Lambeth. While the group has expanded to ten practices (held on time-renewable contracts), including the state-of-the-art Riverside development in Vauxhall – it continues to serve some of the most deprived inner-city populations in the country. The expansion has also led to professional and personal criticism from within the profession and she has been accused of accelerating the creep of commercialisation of general practice – criticism that she tackles head on. “The Hurley Group is pioneering a career structure of GPs that has been praised by Londonwide LMCs. Each practice has Local Medical Directors; GPs with additional leadership responsibilities supported by an overarching senior management team. These GPs are supported in their leadership role and their responsibilities for which they receive enhanced remuneration. These GPs can then go on to become self-employed practice partners, who are given greater responsibility for the running of the practice in return for a share of practice profits. “I am fully supportive of small practices and was vocal in my views against large polyclinics with a pile-’em-high mentality of general practice. What I am in favour of, and feel is the best way of protecting the best of general practice against big business, is that practices should form federations – sharing staff, back office functions and commissioning budgets. The debate of the relative benefit of partnership versus salaried GPs continues, which Dr Gerada feels sometimes clouds the issue of GP leadership facing general practice. She says: “We have to empower the next generation, and to do this we have to create leadership opportunities for those GPs who want them. Of course, those opportunities include partnerships, but they also include opportunities in education, research and medical politics. The next generation are our leaders of the future, and we have a responsibility to provide guidance and opportunity to those that want it.”
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AS A LONDON-BASED GP joining a team that already includes another London GP, RCGP President Iona Heath, she is concerned that some RCGP members might view her tenure as overly London-centric, but she is quick to provide reassurance. “I am the first London-based Chair since Dr Bill Styles in 1996 and London – our wonderful, vibrant capital city – is where the largest congregation of people, and more importantly, doctors live. 27,000 doctors live or work within the greater London area – which is a phenomenal percentage of the medical profession. “However I will be a Chair for the whole of the College, not just for London, and clearly part of my role will be to get RCGP NEWS • MAY 2010
out beyond the London area and ensure that I don’t get preoccupied with issues that are irrelevant outside the capital. The issues in London, or in England or Wales, are not the same issues being faced in Scotland and Northern Ireland and I will be relying on the chairs of the devolved countries, our faculty leads and the nationally elected reps to guide me and ensure that I am making the right decisions on behalf of all our members.” She describes her London-based situation as “paradoxical”: “Some people say being in London will make it easier, but actually since there is no travelling time – and I get everywhere on my bike – there’s no space to catch up on things like emails, phone calls and reading the papers. I suspect that my being in London will leave me with very little time to do the things I might otherwise be able to cram in to a two or three hour train journey.” Having spent the past two and a half years working as Vice Chair alongside Professor Steve Field, she is also under no illusions about the huge workload she is taking on. “I’ll work very hard; I’m used to working very hard and I will make this work. I’ve seen the hours that Steve has put in as Chair but I’m undaunted by this. “I’m going to become a ‘sleeping partner’ of my practice so that I can maintain some clinical work without any conflict of interest with my role as Chair of Council. I will of course still be a partner of my organisation and will still have partnership responsibilities, although these responsibilities will greatly reduce.” As well as her College responsibilities, she is determined to honour other various professional commitments, particularly to the Practitioner Health Programme which helps doctors with problems such as alcohol or substance misuse. “I have made a commitment to continue the clinical input
❛ My priority will be, and has always been, the protection of generalism and preserving the future of general practice ❜
into the Practitioner Health Programme. I feel that managing the problems of sick doctors is something that must remain a high priority.” FOR THE FIRST TIME in College history, Dr Gerada will head a predominantly female team of Officers but she describes this as ‘coincidence’ rather than intention and hopes it will open up the debate on how far women, and men, are able to progress in achieving their professional aspirations. She says: “We are a team of women, and inevitably, this will encourage questions around how women lead, and, more crucially, how women lead men. I do believe that women lead in a different way to men, and I have a sneaking suspicion that people will see a group of women in charge and consider us to be quite threatening.” Perhaps more importantly, Dr Gerada says that her election sends out a clear message to those who think they cannot juggle the dual responsibilities of a professional and personal life. “I hope we will serve as role models for women out there who want to lead lives that include having children, going on holiday and having a life outside work. We’ll emphasise that, whether you’re a man or a woman, you’ll have to make choices and it’s worth bearing in mind that missing the school nativity play is probably going to affect you more than it will your child.” A notable feature of Professor Steve Field’s Chairmanship has been his enormous expansion of the College’s media profile – something that Dr Gerada is keen to continue herself, despite being well aware that it carries with it a double-edged sword. “I really enjoy media work, and I’ve learned a lot over the past few years. Perhaps, most importantly, I’ve learned how terribly misquoted one can be. I think it would be fair to say that you’re safer in print if you write it yourself!” So considering everything that she has packed into her career so far, what is her greatest achievement? “Having spent my life working with hard-to-reach groups, including drug users, and patients with mental health problems, I have to say that it would be setting up the RCGP Substance Misuse Unit. “Aside from the MRCGP, the Substance Misuse Unit is the largest education programme the College has ever had: around 10,000 GPs and other health professionals have now been trained to Certificate Level One. If I was remembered for anything, I would like it to be for transforming the care that drug users get from primary care in the UK.”
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NEWS
Greg takes the AiT chair Global partnership promotes good health Greg Irving has succeeded Clare Taylor as new Chair of the RCGP Associates in Training (AiT) Committee, representing the voice of GP trainees on the RCGP Council.
Greg graduated from the University of Nottingham in 2004 and completed his foundation training at the Queens Medical Centre, Nottingham. He went on to finish a medical rotation in Manchester before taking up General Practice training in the Mersey region. He currently works as an ST4 Academic Clinical Fellow at the University of Liverpool in the Division of Primary Care. He is completing a Masters in Public Health and will shortly be starting a PhD based on complex needs at the end of life. Greg said: “It’s a great honour and privilege to be elected as the new Chair of the AiT committee. I have been involved with the committee for a number of years and have seen it go from strength to strength in a relatively short space of time. The committee now has a representative on all the main committees involved in GP training within the RCGP and on a number of external bodies such as the BMA and the Academy of Medical Royal Colleges. “The College is keen to represent the interests of all GP trainees. We are aware that you represent the future of general practice and it is important that we offer you the support you deserve throughout training. At our last AiT meeting we were particularly pleased to welcome Amanda Watterson as our first ever Northern Ireland representative on the committee.
Improving Global Health through Leadership Development is an exciting new partnership between NHS Education South Central (NESC) and Mbola Millenium Villages Project (MVP) in Tanzania. Elisa Barcellos, a GPST2 at Lilliput Surgery, Poole, Dorset, describes her recent experiences as part of the pioneering group of NHS fellows in Tanzania.
Greg Irving: It is crucial that the College offers GP trainees all the support they deserve “I look forward to meeting many of you at this year’s RCGP annual conference in Harrogate in October. We hope to build on the success of last year’s Glasgow conference, attended by over 200 UK-based and international GP trainees. We have a very exciting programme planned and hope that this year’s conference will leave you feeling both inspired and proud to be a GP trainee.”
Europe canvasses views on GP training in the UK jessica watson RCGP Junior International Committee What is GP training like in other countries? How do other primary care systems work? Are trainees better off in the UK or elsewhere? These are some of the questions that the newly formed RCGP Junior International Committee was set up to explore. At last year’s RCGP conference in Glasgow the Junior International Committee hosted its first international exchange, which looked at some of these questions through a series of fascinating debates. Nineteen delegates from 16 European countries attended, and there was a passionate debate for and against the motion ‘GP training must be the same in every country in Europe’. Ultimately the house decided that although training need not be the same across Europe, standards did need to be the same, and this was something we should all strive to achieve. So how can we help to achieve this goal? How satisfied are our trainees and newly-qualified GPs with the UK training system; and how does this compare to our European counterparts? To explore this, the Vasco da Gama Movement – the group for young and future GPs within WONCA Europe – has designed a questionnaire to look at motivation and satisfaction with GP training, which is being delivered to GP trainees and GPs within five years post-qualification right across Europe. This ambitious project offers the opportunity to compare our training model to the diverse alternatives in place in other countries. With the support of the RCGP First5 and AiT networks, the Junior International team will coordinate the UK arm of this questionnaire, inviting all AiTs and GPs within the first five years of qualifying to participate by email. The questionnaire looks at the coverage of the six core GP competencies defined by the 2002 WONCA Europe consensus statement; The European Definition of General Practice (www.woncaeurope.org/ Definition%20GP-FM.htm). This definition has helped shape Europe-
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wide agendas for education, research and quality improvement, and was adopted in 2005 by the European Academy of Teachers in General Practice (EURACT). The six core competencies defined in document are: ● Primary care management ● Community orientation ● Specific problem solving skills ● Comprehensive approach ● Person-centred care ● Holistic approach Some of these competencies will be familiar to current trainees as the WONCA European Definition of General Practice was used as the basis for the UK general practice curriculum. This means results can be used to feedback directly into future UK curriculum developments. So will we conclude that GP training must be the same in every country in Europe? We don’t think so. But the different training systems across Europe offer a valuable opportunity for us to learn from each other. So let’s listen to what trainees and young GPs have to say. Trainees and First5 GPs are urged to participate in this questionnaire and help influence GP training in the UK and across Europe – look out for the email inviting you to take part. ■ If you would like to find out more about the Junior International Committee, please get in touch: jessicawatson@doctors.org.uk or www.jintc.org
take part in national training surveys 2010 ■ The National Training Surveys 2010 have gone live across the UK. The Surveys Resource Pack web is available at www.pmetb.org.uk ■ The Postgraduate Medical Education and Training Board (PMETB) merged with the General Medical Council on 1 April 2010. All enquiries regarding postgraduate medical education and training should now be directed to the GMC: www.gmc-uk.org
NESC’s partnership with Mbola MVP in Tabora, Tanzania marks the latest step in its innovative leadership development programme and follows on from a successful, ongoing partnership with Samlaut MVP in Cambodia. The project was established in response to Lord Crisp’s Global Health Partnerships Report (2007)1, which highlighted the need for the NHS, as a global employer, to support the scaling up of training, education and employment of health workers in developing countries and recognise the value of overseas training and experience for NHS staff. The Medical Leadership and Competences Framework (2009)2 states that an NHS doctor must be: a practitioner, a partner and a leader. It calls for the development of leadership skills so doctors can become more actively involved in the planning, delivery and transformation of health services. Our aim, through a working collaboration between the NHS and MVP, is to support the Government of Tanzania in Tabora region to achieve sustainable and measurable improvements to healthcare. This provides a unique personal and leadership development experience for NHS international fellows, enabling them to bring new skills to their roles when they return, meeting the requirements expressed in Lord Darzi’s Next Stage Review (2008)3 to develop clinical leadership in the NHS. Fellows are supported with pre-departure leadership training, an educational supervisor during their placement and ongoing input upon return to the UK.
Mbola Millenium villages Project The MVPiv (led by the Earth Institute at Colombia University, Millennium Promise and the United Nations Development Programme) aims to establish a rigorous proof of concept for a settings approach where local communities in rural Africa implement the practical interventions needed to achieve the UN Millennium Development Goals (see panel, top right), over a fiveyear timeframe, within a specified budget. Following a successful start, existing village clusters are being expanded and new ones are being established. Recognising that health is determined by a number of factors, of which healthcare is only one, the MVP operates in a multifactorial context, also focusing on nutrition, education, environmental sustainability and economic growth. Despite being one of the most politically stable countries in sub-Saharan Africa, Tanzania remains incredibly poor, ranked 151st out of 182 countries in the last Human Development Report (2009). The Mbola Millennium Villages cluster, established in February 2006, is in the rural region of Tabora in Western Tanzania. It comprises 15 villages, widely spead over an area of 1,334 sq km, with a population of 34,000 and five dispensaries delivering free primary healthcare. The economy is mainly subsistence farming, based on rain-fed agriculture and production of local livestock breeds.
healthcare in tabora The first group of international fellows to arrive in Tabora, in October 2009, were two GPs (Perminder Sethi and Nicola Prys-Jones), a gastroenterology SpR (David Sheppard) and myself. We worked closely with the Mbola MVP Health co-ordinator, Dr Mjungu (a dentist) and the Regional Medical Officer, Dr Mhina. Tanzania has less than one doctor and four nurses per 10,000 population, compared with 23
doctors and 128 nurses in the UK (WHO: Tanzania 2002, UK 1997)5. Dispensaries provide primary healthcare to thousands of people and represent the closest thing to a GP surgery, without the GPs! Due to the lack of doctors in Tanzania, community healthcare is delivered by clinical officers (three years’ training) or nurses, assisted by auxiliary nurses (one year’s training) or community health workers (CHWs, no formal training). Services include a labour room for uncomplicated deliveries; dispensing of medications (done by CHWs due to the lack of pharmacists); rapid diagnostic tests and iv fluid resuscitation. In some areas, a healthcare centre or a district hospital exists to provide secondary care to the local population, but the closest hospital to Mbola was the regional referral centre, Kitete Hospital in Tabora, a 36km walk from the villages. Ilolangulu dispensary is being upgraded to a health centre, to provide basic surgical facilities including caesarean section and inpatient beds locally.
developing sustainable change We used the Review, Agree, Implement and Demonstrate (RAID) model (Rodgers, 2006)6 to enable local health workers to initiate improvements to their healthcare system. Reviews highlighted a number of possible project areas, particularly TB (Tabora has artificially low rates compared with other regions; despite similar HIV rates, underdiagnosis is predominantly attributed to poor awareness, reluctance to seek a medical opinion and poor access to laboratory facilities to test sputum for open pulmonary TB) and family planning/sexual health. (There is an unmet need for modern family planning, male reluctance and high rates of sexually transmitted infections.) After discussion with relevant stakeholders a number of projects were agreed, including: ● A ‘cough proforma’ to aid diagnosis of TB ● TB education – training for qualified staff on TB/HIV co-infection and a separate session for CHWs, pitched at their level, to promote increased awareness amongst the community ● Transport of sputum samples to Kitete Hospital to avoid patients having to travel there for diagnosis ● Development of a new laboratory facility at Ilolangulu Health Centre for on-site diagnosis ● A ‘Men’s Health Day’ to promote sexual health awareness and acceptance of family planning amongst influential males ● Research into supply of modern family planning methods (currently erratic) ● Family planning outreach clinics Working in a new environment and culture required patience and persistence to develop a good understanding of the local community and organisational structure, enabling the projects to be implemented effectively. Weekly meetings with the local heath team encouraged them to take the lead and own the solutions. A monthly report with a week-by-week outline for the preceding and coming month provided structure to the projects and a good record for handover to future fellows. Audits were used to demonstrate change and although this project is in its infancy, it is hoped that local health workers will be empowered to embed many of the changes over time.
what now? Readjusting to life in the UK was fairly smooth, apart from the slight climate shock, coming from stifling heat to an unremitting ‘cold snap’ with snow and ice! The running water (toilets and showers!), continuous electricity and supermarkets were initially a delightful novelty, but I soon missed the smiling and unchanging face of the cashier from my corner shop, the cycle to work and neighbourhood children playing in the street. At work, I accustomed myself quickly to the usual winter viruses and bouts of depression that I hadn’t seen for the preceding months and RCGP NEWS • MAY 2010
NEWS
Interface Geriatrics: New models of care are needed for the 21st century population Professor Louise robinson RCGP Clinical Champion for Ageing and Older People’s Health and Wellbeing
The UN Millennium Development Goals was pleased to put HIV, TB and malaria much lower down the list of differentials! The partnership is developing, with overlap between NHS fellows (who each spend three to six months) providing continuity, and the health projects continue to evolve. In the meantime, I will be presenting our experiences at the WONCA World Conference 2010 and concentrating on completing my GP registrar training! I feel proud to have been a part of the pioneering group and feel that the combination of leadership development through quality improvement to healthcare systems in the developing world is a new and rewarding concept that promises to benefit all involved. Many thanks to the team at NESC, particularly Fleur Kitsell, for all their hard work in arranging the partnership; Lilliput Surgery and Wessex GPVTS for supporting my OOPE; and Perminder, Nicola and David for their continued enthusiasm, even in the face of D&V and malaria!
references 1. Crisp, N. Global Health Partnerships: the UK contribution to health in developing countries. 2007 2. Medical Leadership Competency Framework: Enhancing Engagement in Medical Leadership. 2nd edition. 2009 3. Darzi, A. High Quality Care For All: NHS Next Stage Review. 2008 4. http://millenniumvillages.org 5. www.who.int/research/en 6. Rodgers, PG. RAID Methodology: The NHS Clinical Governance Team’s approach to service improvement. Clinical Governance: An International Journal 2006; 11(1):69-80
■ If you would like to find out more about the Junior International Committee, please get in touch: jessicawatson@doctors.org.uk or www.jintc.org
Our populations are changing. Soon people over 65 years of age will outnumber those under 16 and the oldest old, the over-85s, are the fastest growing sector of the population. The majority of care for our ageing populations will undoubtedly rest with primary and community care teams, with perhaps more than a little help from our friends in geriatrics and old age psychiatry needed! Previously, much of the acute care and rehabilitation of older people was delivered in acute hospital settings. Currently this care is delivered predominantly in acute medical units (AMUs) with ongoing rehabilitation provided in a variety of community settings, including intermediate care schemes (home based or residential) and community hospitals. The consequence of these changes is unclear, but in some centres the outcomes for frail older people attending AMUs is worrying; following community discharge up to 55 per cent are readmitted and 26 per cent die in the following 12 months1. One solution would be to develop jointly funded services which bring together primary care and acute hospital trusts and perhaps, if we are being truly daring and risky, the ultimate challenge of combined health and social care budgets! New models of care are needed to meet the needs of our 21st century populations. Such is the rationale behind the concept of interface geriatrics; geriatricians working at the front door (either the emergency department or the acute medical unit or both), identifying who needs to be admitted and for how long and who would be better served by community-based multidisciplinary teams. Interface geriatrics was the focus of a conference jointly hosted by the RCGP and the British Geriatric Society to explore new models of caring for older people in the community and brought together primary, secondary and social care (www.bgs.org.uk). Presentations at the conference illustrated some examples of such innovative practice such as the Front Door Assessment and Care Team (FACT). This is a multidisciplinary team, comprising physiotherapy, occupational therapy and nursing (some team members also have knowl-
Healthy development in Tanzania: Nicola (left) and Elisa (right front) at the Care and Treatment Clinic (CTC) Club for HIV+ children RCGP NEWS • MAY 2010
edge of social services assessment), which is based in the Accident and Emergency Department of an Acute Hospital. The roles of the team are to act as the ‘older peoples champion’ in the emergency department and acute medical assessment units, to ensure timely and safe discharges of older people from these departments, and to provide links to other essential professional and voluntary services. Several presentations summarised evidence for the clinical and cost effectiveness of Comprehensive Geriatric Assessment (CGA)2. CGA comprises six key elements: functional ability; cognitive assessment and function; physical health; nutritional status; mobility and falls and socioeconomic status. CGA is usually provided through mult-disciplinary teams. The importance of collaboration and creating ‘teams without walls’ was highlighted. An interesting model from Gwent, to care and support frail, older people in the community, was presented by Professor Khanna. The Gwent Integrated Intermediate Care Model comprised interagency working across health and social care but also encompassed the ambulance services and the voluntary sector. The model was focussed on identifying those older people at risk of frailty, targeting appropriate interventions to prevent further decline and inappropriate acute hospital admissions, and supporting older people to remain in their home where possible. This whole system model provided urgent comprehensive geriatric assessment and in a crisis, a rapid response health intervention and social care crisis intervention. Dr Simon Conroy and I provided views from the ‘coalface’ of the current issues facing primary and secondary care respectively of caring for older people. I presented some early data from the Newcastle 85+ Study3, a large cohort study exploring the health of 800 85-year-olds. Initial data suggests that although this group have considerable multi-morbidity, their self-rated health and level of functioning is relatively good. Most are living independently in the community but considerable support is provided through family and informal care networks. Interestingly, the challenges identified by the primary and secondary care speakers in caring for older people were almost identical and included: multi-morbidity; cognitive impairment; polypharmacy; functional decline; frailty; carer support and palliative care for people with long term conditions. The role of another important community professional, the community matron, in caring for older people and people with long-term conditions was discussed. These are highly skilled nurses, usually employed by practice based commissioning groups, working across primary, secondary and social care boundaries. The role of the community matron is teaching and supporting other community professionals was highlighted. A fascinating presentation came from Professor Colin Currie, a geriatrician in Scotland but also Special Advisor to the Policy Unit, 10 Downing Street. He presented data which revealed a widespread postcode lottery in the care received by older people. Currently the probability of people aged over 75 years experiencing multiple hospital admissions ranges from 2.5 to 9.5 per cent across English Primary Care Trusts. The probability of acute hospital admissions for people aged over 85 years resulting in a care home admission ranged from five to 20 per cent. Equally staggering was the fact that the proportion of total local authority budget spent on care home care nationally ranges from 25 – 71 per cent (average 51 per cent).
Professor Robinson: An opportunity to review all aspects of care for elderly people Professor Currie stated that these variations are unacceptable, especially as the money the NHS spends on the over-65s accounts for more than 60 per cent of acute sector costs and 60 per cent of social care spend. He argued that the continued separation between health and social care budgets was a legacy of the early NHS which was not meeting the needs of a 21st century population. Professor Currie then presented examples, from Torbay and Isle of Wight, of multi-agency collaborations who were providing cost-effective, system-wide services for older people through early supported discharge and rehabilitation at home following acute admission, home care for frailest who did not want care home admission, and palliative care at home. The overall message of the conference was that ageing and the care of older people is everybody’s business. We need responsive, flexible collaborative care, with better integrated health services and local care provision. A National Care Service, rather than a National Health Service, would appear to be better suited to meet the needs of our rapidly ageing patients, and we need it very soon! However we as general practitioners also need to consider very carefully whether our current training and the services we provide are fit for purpose at a time when the proportion of very elderly people in the population is rising dramatically. Within the current postgraduate training, a GP may have had little experience of caring for older people. The Diploma in Geriatric Medicine (www.rcplondon.ac.uk) is available to general practitioner vocational trainees, clinical assistants and others working in non-consultant career posts in departments of geriatric medicine, and provides the opportunity to review and consider all aspects of the care of elderly people and to be recognised as having this knowledge. Unfortunately the numbers of GPs currently undertaking the DGM compared to other specialist diplomas is low! ■ For more information on the RCGP Clinical Priority Programme and the Clinical Champions, please contact the Clinical Innovation and Research Centre (circ@rcgp.org.uk /0203 170 8231) www.rcgp.org.uk/circ ■ To register your special interest via the RCGP CIRC Expert Resource Database, please visit www.rcgp.org.uk/expert or contact expert@rcgp.org.uk
references 1. Woodard J, Gladman J, Conroy S. Frail Older People at the Interface. JNHA 2009;13 (suppl 1 S308) 2. Caplan GA, Williams AJ, Daly B et al. A Randomized, Controlled Trial of Comprehensive Geriatric Assessment and Multidisciplinary Intervention After Discharge of Elderly from the Emergency Department; The DEED II Study. Journal of the American Geriatrics Society 2004;52(9):1417-1423. 3. Collerton J, Davies K, Jagger C, Kingston A, Bond J, Eccles M, Robinson L, Martin- Ruiz C, von Zglinicki T, James O, Kirkwood T. Health and disease in 85 year olds: baseline findings from the Newcastle 85+ cohort study. BMJ 2009; 399:b4904 doi: 10.1136/bmj.b4904.
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CLINICAL UPDATE
Atrial fibrillation and antithrombotic therapy Stroke/TIA (maximum six points). The annual risk of stroke is greater with a higher points score and ranges from 1.9 per cent to 18.2 per cent (equivalent to zero points and six points respectively). Patients can be classified accordingly into low, moderate and high risk groups (zero points = low risk, one point = moderate risk, ≥ two points = high risk) to help guide decisions on the prescription of antithrombotic therapy.
david A Fitzmaurice Md FrcgP Professor of Primary Care Primary Care Clinical Sciences, University of Birmingham jaspal s taggar MrcP GP Registrar East Midlands Healthcare Workforce Deanery sarah j johns BMBs GP Registrar Severn Deanery
how can we prevent stroke in AF?
Atrial Fibrillation (AF) is the most common sustained cardiac arrhythmia encountered in clinical practice. AF has a prevalence which increases with age and epidemiological studies calculate it to be present in around 8.5 per cent of people over the age of 65 years, more than 12 per cent in the over-75 population, and is continuing to increase in both prevalence and incidence. AF is associated with significant morbidity and mortality and it is estimated to utilise around one per cent of the United Kingdom National Health Ser vice expenditure, thus posing a significant health and economic burden.
In addition to controlling the cardiovascular risk factors for stroke (many of which are also risk factors for the development of AF), the mainstay of stroke prevention in AF is the use of antithrombotic therapy. Results from randomised controlled trials (RCT) and meta-analyses show that appropriate antithrombotic treatment reduces the risk of stroke by a staggering 64 per cent, making this one of the most effective interventions we have at our disposal. It is becoming increasingly recognised that patients requiring stroke prevention should be treated with warfarin, or alternative anticoagulants, with anti-platelet agents only really of use in those patients who are genuinely intolerant of oral anticoagulants.
what are the problems associated with AF? Morbidity and mortality associated with AF results from the combination of its haemodynamic effects, thromboembolic risk and the burden of treatment. Ultimately, a patient may experience an array of symptoms (such as palpitations, breathlessness, dizziness and chest pain), disease progression and the development of heart failure. Furthermore, AF results in a hypercoagulable state by fulfilling the virtues of Virchows triad and therefore particular attention is drawn to its thromboembolic complications, in particular stroke. As initially demonstrated in the Framingham Heart Study, AF is an independent risk factor for stroke with the risk of stroke around five-fold greater for those with AF. It is estimated that AF is present in up to as many as 15 per cent of patients presenting with an acute stroke or Transient Ischaemic Attack (TIA). However, the risk of stroke is not homogenous for all patients and this has led to the development of schemata that categorise risk, such as that employed in the National Institute for Health and Clinical Excellence (NICE) guidelines for AF. However, in clinical practice alternative validated stroke risk stratifying schemata are often used in place of the NICE algorithm. The CHADS2 scoring system provides more simplicity in estimating risk with patients being scored one point for the co-morbidities Congestive cardiac failure, Hypertension, Age ≥ 75, Diabetes and two points if there is a prior history of
what are the problems associated with the use of anticoagulation? Safe use of anticoagulant therapy can be a challenge to primary and secondary care physicians. Although there are clear benefits to be gained from antithrombotics, stroke prevention must be balanced against the risk of side effects and complications from therapy. Physicians generally are concerned with the bleeding risk from oral anticoagulation agents, in particular gastrointestinal and intracranial haemorrhage. Patients tend to be more risk averse to stroke. It is for these reasons and the perception that warfarin therapy is in itself difficult that anticoagulation is underutilisation. Patient factors that have been shown to convey a greater risk of bleeding, and therefore warrant recognition, include: ● Increasing age (particularly age > 75 years) ● Concomitant treatment with antiplatelets or non-steroidal anti-inflammatory drugs ● Concomitant treatment with other multiple drug therapies ● Poorly controlled hypertension ● Poorly controlled (previous or current) anticoagulation therapy (particularly INRs > 4.0) ● Past history of bleeding problems (peptic ulcer disease or cerebral haemorrhage) Whilst it is deemed essential to assess bleeding risk as part of clinical assessment before
starting a patient on anticoagulation therapy, this is rarely formally undertaken, perhaps because these factors are also those which place the patient at highest risk of stroke. The Birmingham Atrial Fibrillation Treatment of the Aged (BAFTA) study, a randomised controlled trial (RCT) in a primary care setting, assessed the efficacy and safety of warfarin (INR 2-3) compared to aspirin 75mg. This was a unique study with the recruitment of an elderly population with AF (Age > 75 years; N=973 with mean age 81.5 years), who were followed up for a mean of 2.7 years. The study showed there to be a non-significant difference in the annual risk of all major haemorrhagic complications in patients treated with warfarin as compared to aspirin (1.9 per cent versus 2.0 per cent respectively). Furthermore, the BAFTA study showed warfarin, as compared to aspirin therapy, to be associated with a significant reduction in the annual risk of all cause stroke [2.5 per cent versus 4.9 per cent, RR 0.52 (95 per cent CI 0.33– 0.80), p = 0.002]. Certainly, the findings from the BAFTA investigators suggest that anticoagulation therapy in well selected elderly patients is a safe treatment (as compared to aspirin) offering a substantial reduction in the risk of stroke.
what is the future for anticoagulation therapy with AF? New and novel therapies which hope to overcome the problems of initiating, monitoring, interaction and complication of current anticoagulation therapy are under investigation, such as the direct thrombin inhibitors and factor Xa inhibitors. The SPORTIF investigators showed the direct thrombin inhibitor, ximalegatran, to be a non-inferior alternative to warfarin with a better bleeding profile. Ximalegatran was withdrawn from clinical use however, due to an increase in hepatotoxicity. More recently the landmark RE-LY study compared fixed dose dabigatran (two dosing regimens) with adjusted dose warfarin (N = 18,113, mean age 71 years, median follow up 2.0 years). Patients receiving the lower fixed dosing regimen of dabigatran (110 mg bd) had a non-significant difference in the annual incidence of stroke or systemic thromboembolism as compared to warfarin (1.53 per cent versus 1.69 per cent). However, the use of dabigatran in this arm of the trial was associated with a lower annual incidence of major bleeding complications [2.71 per cent versus 3.36 per cent , RR 0.80 (95 per cent CI 0.69 – 0.93), p = 0.003]. In comparison, patients receiving the higher fixed dosing regimen of dabigatran (150 mg bd) had a significantly lower annual incidence of stroke or systemic thromboembolism [1.11 per cent versus 1.69 per cent, RR 0.66 (95 per cent CI 0.53 – 0.82), p < 0.001], and although overall bleeding
rates were similar there was a significantly greater annual incidence of major gastrointestinal bleeding [1.51 per cent versus 1.02 per cent, RR 1.50 (95 per cent CI 1.19 – 1.89), p < 0.001]. The findings from the RE-LY study are promising and suggest dabigatran may be an effective alternative to warfarin in stroke prevention. The introduction of newer agents is likely to change the landscape of anticoagulation use in AF patients and it will be interesting to see the effect of increasing treatment options for these patients over the next few years. ■ Contact: D.A.Fitzmaurice@bham.ac.uk/ +44(0)121 414 7420
references Connolly SJ, Ezekowitz MD, Yusuf S, Eikelboom J, Oldgren J, Parekh A, Pogue J, Reilly PA, Themeles E, Varrone J, Wang S, Alings M, Xavier D, Zhu J, Diaz R, Lewis BS, Darius H, Diener HC, Joyner CD, Wallentin L; RE-LY Steering Committee and Investigators. Dabigatran versus warfarin in patients with atrial fibrillation. New England Journal of Medicine (2009)17;361:1139-51 Fitzmaurice DA, Hobbs FDR, Jowett J, Mant J, Murray ET, Holder R, Raftery JP, Bryan S, Davies M, Lip GYH, Allan TF. Screening versus routine practice in detection of atrial fibrillation in patients aged 65 or over: cluster randomised controlled trial. BMJ 2007; 335:383-386 Gage BF, Waterman AD, Shannon W, Boechler M, Rich MW, Radford MJ. Validation of clinical classification schemes for predicting stroke: results from the National Registry of Atrial Fibrillation. JAMA 2001; 285: 2864–70 Hart RG, Pearce LA, Aguilar MI. Meta-analysis: antithrombotic therapy to prevent stroke in patients who have nonvalvular atrial fibrillation. Ann Intern Med. 2007; 146:857-67 Mant J, Hobbs FD, Fletcher K, Roalfe A, Fitzmaurice D, Lip GY, Murray E; BAFTA investigators; Midland Research Practices Network (MidReC). Warfarin versus aspirin for stroke prevention in an elderly community population with atrial fibrillation (the Birmingham Atrial Fibrillation Treatment of the Aged Study, BAFTA): a randomised controlled trial. Lancet 2007; 11;370:493-503 National Collaborating Centre for Chronic Conditions. Atrial fibrillation: national clinical guideline for management in primary and secondary care. London: Royal College of Physicians, 2006 Olsson SB; Executive Steering Committee of the SPORTIF III Investigators. Stroke prevention with the oral direct thrombin inhibitor ximelagatran compared with warfarin in patients with non-valvular atrial fibrillation (SPORTIF III): randomised controlled trial. Lancet 2003 Nov; 362:1691-8 Stewart S, Murphy N, Walker A, McGuire A, McMurray JJ. Cost of an emerging epidemic: an economic analyisis of atrial fibrillation in the UK. Heart 2004; 90:286-292 Sudlow M, Thompson R, Thwaites B, Rodgers H, Kenny RA. Prevalence of atrial fibrillation and eligibility for anticoagulants in the community. Lancet 1998; 352:1167-1171
New NICE guidance: Changes in the management of unstable angina and non-sT elevation myocardial infarction (NsTEMI) dr norma o’Flynn Clinical Director National Clinical Guideline Centre Acute and Chronic Conditions The National Institute for Health and Clinical Excellence (NICE) has published two new linked guidelines. Clinical Guideline 94 Unstable angina and NSTEMI addresses the early management of these conditions; Clinical Guideline 95 Chest Pain of recent onset deals with the investigation of chest pain up to the point of diagnosis of either ACS or stable angina. Areas of both these guidelines are relevant to general practitioners, either in initial investigation and management or for follow-up of patients following specialist investigation and treatment. A paper outlining the recommendations from the guideline on Chest pain of recent onset will be published in the British Journal of General Practice in August 2010.
6
Management of unstable angina and nsteMi While the diagnosis of acute coronary syndromes are covered by Guideline 95, management of unstable angina and NSTEMI from the point of diagnosis are dealt with in Guideline 94. The majority of general practitioners will not be involved in the care of patients with suspected acute coronary syndromes, but we will see patients following their admission with a cardiac event. The guideline on management of unstable angina and NSTEMI recommends interventions for this group of patients according to their risk of cardiovascular mortality over six months. Risk estimation is carried out using a validated scoring system and this risk estimation guides appropriate treatment for each patient. The factors that are included in risk score system are clinical history (age, previous MI, previous revascularisation), findings of physical examination and investigations such as blood pressure and heart rate, 12 lead resting ECG and blood tests (such as troponin I/T, creatinine, glucose and haemoglobin). An assessment of bleeding risk is also nec-
essary. High bleeding risk is associated with advancing age, known bleeding complications, renal impairment and low body weight. All patients should receive a loading dose of aspirin 300mg and aspirin continued indefinitely. Fondaparinux (a synthetic heparin-like drug) should be offered to all patients without a high bleeding risk unless angiography is planned within 24 hours (if bleeding risk is high unfractionated heparin is preferred). Other drug treatment and investigation is influenced by the patient’s six-month cardiovascular mortality risk. Patients whose six-month cardiovascular mortality risk is ≤1.5 per cent will not be given clopidogrel, so we will see patients discharged following a NSTEMI who are not taking clopidogrel! All patients whose six-month cardiovascular mortality risk is >1.5 per cent should get clopidogrel and remain on this for one year. Patients whose six-month cardiovascular mortality risk is <3 per cent should have initial conservative management without early coronary angiography. If these patients experience subsequent ischaemia or are shown to have ischaemia on further investigation then assessment by angiography is suggested.
Glycoprotein inhibitors (11b, 111a) or bivalirudin are recommended for patients whose six-month cardiovascular mortality risk is >3 per cent, and these patients should be offered coronary angiography within 96 hours of first admission and as soon as possible for a patient who is critically unstable or at high ischaemic risk. Ischaemia testing before discharge is recommended for patients who have not had coronary angiography and measurement of left ventricular function if recommended for all patients. Following discharge all patients should have access to cardiac rehabilitation and secondary prevention strategies. ■ The full details of both guidelines can be found on the NICE website http://guidance.nice.org.uk/ CG94 Unstable angina and NSTEMI and http://guidance.nice.org.uk/ CG95 Chest pain of recent onset NICE is currently developing a guideline on the Management of Stable Angina which will complement these guidelines. RCGP NEWS • MAY 2010
CLINICAL UPDATE
Headache care in general practice Here is the third in a series of five RCGP factsheets supporting the diagnosis and management of headache in primary care. Written by RCGP Clinical Champion for Headache Dr David Kernick, the factsheets are also published by GP newspaper at www.healthcarerepublic.com/go/rcgp
FACT FILE 3: MIGRAINE introduction Migraine is the main cause of high impact headache and affects 7.6 per cent of males, 18.3 per cent of females and 12 per cent of children. Unfortunately, the majority of sufferers are reluctant to seek help and when they do the condition is less than optimally managed. Migraine is co-morbid with depression and anxiety disorders, epilepsy and asthma.
MAKing the diAgnosis Migraine is the most common headache presentation in primary care. Although the International Headache Society criteria (see box on right) are quite specific, from a clinical perspective they may be relaxed. Answering yes to two out of three simple questions effectively identifies migraine sufferers: ● Has a headache limited your activities for a day or more in the last three months? ● Are you nauseated or sick to your stomach when you have a headache? ● Does light bother you when you have a headache?
the stAges oF MigrAine ● Prodrome 30-50 per cent of migraineurs –
sensory or psychological features that can occur up to 48 hours prior to attack. Prodrome, eg craving for a particular food can be confused with a trigger. ● Aura 30 per cent of migraineurs – a reversible sensory or motor phenomena of cortex or less commonly brainstem lasting under 60 minutes. Visual auras are the most common followed by paraesthesie. Atypical auras can occur, eg. vertigo, hemiplegia. Aura can occur in the absence of headache. As they are caused by a spreading cortical depression, their evolution with time distinguishes from TIA. ● Headache 60 per cent unilateral, throbbing or pulsating. Associated with nausea or vomiting, photophobia or phonophobia. Increased skin sensation can also occur. ● Postdrome – tiredness, elation.
the eMergencY cALL out ● Parenteral summatriptan treatment of
●
choice. ● IM diclofenac 50mg with IM antiemetic second line. ● Avoid opiates. Dependency soon develops.
MAnAgeMent oF the Acute AttAcK
●
● A useful first line of treatment that can be
FORMAL CRITERIA FOR A MIGRAINE DIAGNOSIS (Can be relaxed in practice) At least five attacks fulfilling criteria - Headache attacks lasting 4 to 72 hours
(untreated or unsuccessfully treated) Headache has at least two of the following characteristics: ● Unilateral location ● Pulsating quality ● Moderate or severe pain intensity ● Aggravating or causing avoidance of routine physical activity During headache, at least one of the following: ● Nausea and or vomiting ● Photophobia or phonophobia Not attributed to other disorder (A formal diagnosis of migraine therefore must include an examination to exclude another disorder.)
MigrAine triggers
bought cheaply OTC, all of which should be taken together, is: domperidone 10mg, paracetamol 1grm, ibuprofen 400 mg or aspirin 600mg. Soluble preparations act quicker. Can be taken prior to Triptan. Larger initial doses may reach therapeutic levels quicker. (Domperidone 20mg, paracetamol 1.5 grm, ibuprofen 600 mg or aspirin 900mg) providing maximum daily doses are not exceeded. ● If vomiting or severe nausea use domperidone suppositories 30mg and diclofenac suppositories 100mg. ● Triptans. Cornerstone of the acute attack. See table below. Nasal forms (Sumatriptan and Zolmatriptan) useful when gastric stasis is a problem or injectable (Sumatriptan) for intractable cases. Wafer formulations (Zolmatriptan and Rizatriptan) are for convenience only and not absorbed through the oral mucosa. Sumatriptan 50mg is now available OTC. Failure of response to Triptans is not a class effect. If one doesn’t work rotate choices. Treat at onset of pain. May not be effective if taken during aura phase. More effective if taken with anti emetic. Vascular disease an absolute contraindication.
● Often inconsistent. The importance of
allergy remains unproven. ● The often unrecognised trigger is
sensitivity to change, eg glucose, hydration, stress, oestrogen, sleep patterns – keep everything as constant as possible.
PAthogenosis
PreventAtive treAtMent ● No specific indications for using
preventative treatment. The impact upon the patient is the best guide. ● Preventative medication should be given for at least eight weeks at its maximum tolerated dose before its impact should be
●
●
assessed and if successful continued for at least six months. Beta-blockers are the drug of first choice and Propranolol, Metopalol, Timolol and Nadolol are licensed for use in migraine. Atenolol 25 mg increasing to 100mg or the highest tolerable dose appears effective, is cheap and convenient to take. Nebivolol is a useful if side-effects are problematic. Amitriptyline 10mg increasing to 100mg or the highest tolerable dose is the preventative medication of second choice. Works well with a beta-blocker. Anti-epilepsy drugs form the third line choices, particularly sodium valproate (un-licensed) and topiramide (licensed). Gabapentin and lamotrigine are sometimes used. Although licensed, Sanomigran is generally ineffective in adults and weight gain can be troublesome.
ALternAtive treAtMents ● Physical therapies such as biofeedback,
relaxation therapy, cervical manipulation, and cranial massage have are not supported by firm evidence. ● Positive trials have been reported on acupuncture but have been criticised on methodological grounds. ● Butterbur, feverfew, coenzyme Q10 and magnesium have a weak evidence base.
MigrAine in woMen ● Avoid combined oral contraception with
aura or migraine without aura with other vascular risk factors. ● Look for hormone sensitive migraine. Perimenstrual (Mefanamic acid or Naproxen –2d to +2d; transcutaneous oestrogen gel 1.5g/day –5d to +2d; frovatriptan 2.5mg/day –2d to+4d. Perimenopausal (low dose HRT, not oral). ● The majority of women get fewer migraines in pregnancy. Paracetamol and antiemetics are safe. Seek expert advice otherwise.
● Poorly understood. Mid brain migraine
generator activates trigeminal system which causes dural inflammation and pain. ● Migraine generator close to nausea and vomiting centre. Gastric stasis and inhibition of drug absorption major problem. ● Migraine generator overlaps nuclei of upper cervical nerves. Neck and shoulder pain common in migraineurs and probably represents efferent signals and not primary neck problem.
AvAILABLE TRIPTANS Group A (Higher speed onset) Sumatriptan Rizatriptan Zolmatriptan Eletriptan Almotriptan
Group B (Lower headache recurrence, lower side effect profile)
100/50mg 10/5mg 2.5mg 20mg/40mg 12.5mg
Naratriptan Frovatriptan
2.5mg 2.5mg
NICE honour GP expertise needed for guideline development groups for David Kernick NICE is currently recruiting to guideline development groups in the areas outlined in the table below – and RCGP Chairman Professor Steve Field is urging College Members and Fellows to contribute their expertise. Professor Field said: “It is crucial that GPs have a voice in the NICE work. We are at the frontline of patient care, we see more patients per day and per year than any other healthcare professionals and we must make sure that we play a central role in influencing such important and potentially lifechanging decisions affecting our patients.” ■ Further information is available from the Join a committee or working group section of www.nice.org.uk/getinvolved/
GuIDELINE NAME
Recruitment starts for Guideline Development Groups
Management of Crohn’s disease
19 May 2010
Diagnosis and management of lower limb peripheral arterial disease
18 June 2010
Management of incontinence in neurological disease in all ages
23 June 2010
Diagnosis and management of new onset headaches in adolescents and adults
6 August 2010
RCGP NEWS • MAY 2010
Dr David Kernick has been awarded an inaugural NICE Fellowship for his work in general practice. Dr Kernick is one of only ten senior health professionals across the entire NHS to receive the prestigious award which will run for three years. As a NICE Fellow, he will work with other key organisations, both lay and professional, to address the increasing problem of headache in the population, covering three main aspects: ● improving the education of general practitioners and providing guidance in relevant clinical areas ● targeting headache in occupational settings ● improving the identification and management of headache in schools Dr Kernick trained as a chemical engineer but has worked for the last 25 years in a large group practice in Exeter, where he is lead research GP. As well as headache, his research interests
have been in health economics in primary care and complexity theory, particularly from the perspective of organisational theory. He runs an Intermediate Care Headache Clinic for NHS Devon. NICE has appointed the new Fellows and Scholars to encourage senior health professionals to become more actively involved with its work. It aims to establish a network of influential professionals spanning all the major clinical specialties and disciplines who will help drive up the quality of patient care and encourage the introduction of cost-effective innovation into practice.
7
NEWS
Delegates respond well to change RCGP workshops on Achieving a Responsive Practice have proved a great success – with over 1200 GPs and practice managers taking part. Overall, the ten workshops – one for each Strategic Health Authority region – have helped equip staff in 500 practices with the skills, knowledge and confidence to implement changes to improve access and responsiveness for patients. Each workshop was fully booked. Based on the Practice Management Network’s ‘how to’ guide on access and patients responsiveness, the workshops were developed by the RCGP in partnership with the BMA and the Practice Management Network as part of the Department of Health’s GP Access Programme. Delegates learned about Understanding Demand; Managing and Meeting Demand; Telephony; Patient Engagement; Marketing and Communicating; and Understanding Your Community, before leaving with a ‘workshop in a bag’ to take back to their practices.
Supporting carers: The Princess Royal visits one of her charity’s centres
Dr Greg Simons, GP lead for the project said: “We couldn’t be happier with the way things have gone. We’ve had a really good mix of delegates attending the events and some excellent early evaluation: we look forward to receiving more feedback from those practices in three months time.” Delegates completed an online, post-workshop questionnaire and a three-month reflective evaluation will be conducted to capture the changes that delegates have implemented following the events. The project was jointly developed by Dr Simons and Sandy Gower (Practice Manager Lead), with support from Professor Nigel Sparrow, Chair of the Professional Development Board, and Dr Mike Warburton, DH National Director for GP Access. ■ More information can be found on achieving a responsive practice at: http://old.networks.nhs.uk/uploads/ pmnetwork/090702__improving_access_ responding_to_patients_final.pdf
New rCGP award recognises practices’ work with carers A Neighbourly welcome for new GPs The RCGP in partnership with the Princess Royal Trust for Carers is establishing a new award to recognise the excellent work of GP practices in identifying and supporting carers. The inaugural Caring about Carers Award 2010 will be announced at the RCGP Annual National Conference in Harrogate in October. HRH The Princess Royal has been invited to present the awards. GP practices will need to be patient-nominated and there will be an award for each UK country and an overall UK-wide winner. Awards will take the form of a certificate signed by Her Royal Highness and a commemorative plaque to display in your surgery. It is estimated that one in ten patients in every practice is caring for a relative or friend who is sick, disabled, or frail – and it is usually only a matter of time before the carer becomes ill as a result of neglecting his or her own health needs. GPs play a vital role in encouraging carers to look after their own health, as well as providing support to help them in their caring role. The RCGP collaboration with the Princess
Former RCGP President Dr Roger Neighbour will be keynote speaker at the Royal Society of Medicine’s 13th National registrars and new practitioners study day on 10 June 2010.
Royal Trust for Carers is now in its third year and has produced a wide range of resources to support GPs in identifying and supporting carers, including an online toolkit. RCGP Lead Professor Nigel Sparrow said: “Ten per cent of the population are now carers. Carers need support from their GPs, and practices around the UK are doing outstanding work that makes a real difference to carers’ lives. “We are delighted to be working with the Princess Royal Trust for Carers in launching the new Award. As well as being tangible recognition for the work being done by GPs, it will send out a positive message to patients that GPs are a valuable source of support.” To be eligible for this Award, you must be nominated by a patient, using the poster available to download at: www.rcgp.org.uk. The closing date for entries is 11 June 2010. Nominated GPs and practice teams will then be asked to complete a ten question self-assessment checklist which will provide evidence of your practice in some of the key areas of carer support. Deadline is 9 July 2010. This is a shorter version of the checklist in Supporting Carers: An action guide for general practitioners and their teams (2009): www.carers.org/professionals
The meeting – organised by the RSM General Practice and Primary Healthcare section – will introduce registrars and newly trained GPs to the RSM and its resources, as well as discussing issues relevant to daily general practice. ■ See a full programme and register at www.rsm.ac.uk/academ/gpa05.php
Business as usual as rCGP bookshop closes its doors until beginning of new chapter The RCGP bookshop based at Princes Gate has closed until further notice in preparation for the College’s move to temporary accommodation. The online service will continue to operate as normal www.rcgp.org.uk/bookshop where members can purchase a wide range of primary care books and receive a 10 per cent discount on purchases. Customer service will be available as usual. Contact Rachel Babula on 020 7344 3198 or email bookshop@rcgp.org.uk for all enquiries. The usual selection of new and popular books will also be available to view and buy at various RCGP courses and events. The new-look bookshop is expected to reopen in autumn 2012 when College moves to its new permanent headquarters in Euston.
Management in Practice Manchester 8 June 2010 – The Bridgewater Hall
Do you have what it takes to be an award-winning leader?
Now in their fourth year, the national Management in Practice Events promise a rewarding day of training and
Nominations are open for the 2010 NHS National Leadership Awards.
presentations from key figures in the practice management sector. New for 2010, we are proud to announce our new partnership with the RCGP, with an entire stream dedicated to sessions that will benefit not only practice managers, but GPs and partners too.
The awards aim to recognise the achievements of leaders from all levels of the NHS and are open to anyone working for or on behalf of the NHS in England. Videos of last year’s finalists – including the RCGP’s Dr Jag Dhaliwal – can be found at www.youtube.com/departmentofhealth.
In these changing times it is important to build a solid foundation of communication when running your practice – that’s why we have introduced this new stream to broaden learning horizons, generate conversation, bridge gaps, and encourage a team approach to business. Recognising the complex training needs for practice managers and GPs with a professional interest in the way practices are managed, each one-day event will enable you to plan ahead for the future of your practice and
■ Visit www.nhsleadershipawards.nhs.uk for full details. Closing date is 28 May.
equip you to meet personal training objectives in a range of subject areas. The events are held in Manchester, London and Birmingham each year. The Manchester event in June is the first to take place in 2010, to be followed by London on 1 September and Birmingham on 20 October. These events are a unique platform for topical practice management issues to be discussed, experiences of problemsolving shared and valuable training sessions delivered.
Do join us on the day to refresh your personal development and consolidate the quality of management operations in your practice. For more information, please call the team on 0207 214 0598 or visit managementinpractice.com/manchester
FREE ENTRY FREE SEMINARS FREE TRAINING FREE EXHIBITION FREE LUNCH
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RCGP NEWS • MAY 2010